Delayed Ejaculation
DSM-III In DSM-III, this disorder is called Inhibited Male Orgasm For more information, see Psychosexual Dysfunctions Diagnostic Criteria A'''. Recurrent and persistent inhibition of the male orgasm as manifested by a delay in or absence of ejaculation following an adequate phase of sexual excitement. The same individual may also meet the criteria for Inhibited Sexual Excitement if at other times there is a problem with the excitement phase of sexual activity. In such cases both categories of Psychosexual Dysfunction should be noted. '''B. The disturbance is not caused exclusively by organic factors (e.g., physical disorder or medication) and is not due to another mental disorder. DSM-IV In DSM-IV, this disorder is called'' Male Orgasmic Disorder'' For more information, see Sexual Dysfunctions Diagnostic Criteria A'''. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration. '''B. The disturbance causes marked distress or interpersonal difficulty. C'. The orgasmic dysfunction is not better accounted for by another mental disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. ''Specify type: * '''Lifelong Type * Acquired Type Specify type: * Generalized Type * Situational Type Specify type: * Due to Psychological Factors * Due to Combined Factors Differential Diagnosis Sexual Dysfunction Due to a General Medical Condition Male Orgasmic Disorder must be distinguished from a Sexual Dysfunction Due to a General Medical Condition. The appropriate diagnosis would be Sexual Dysfunction Due to a General Medical Condition when the dysfunction is judged to be due exclusively to the physiological effects of a specified general medical condition (e.g., hyperprolactinemia). This determination is based on history, laboratory findings, or physical examination. Sensory threshold testing may demonstrate reduced sensation in the skin on the penis that is due to a neurological condition (e.g., spinal cord injuries, sensory neuropathies). If both Male Orgasmic Disorder and a general medical condition are present but it is judged that the sexual dysfunction is not due exclusively to the direct physiological effects of the general medical condition, then Male Orgasmic Disorder, Due to Combined Factors, is diagnosed. Substance-Induced Sexual Dysfunction In contrast to Male Orgasmic Disorder, a Substance-Induced Sexual Dysfunction is judged to be due exclusively to the direct physiological effects of a substance (e.g., alcohol, opioids, antihypertensives, antidepressants, neuroleptics). If both Male Orgasmic Disorder and substance use are present but it is judged that the sexual dysfunction is not due exclusively to the direct physiological effects of the substance use, then Male Orgasmic Disorder, Due to Combined Factors, is diagnosed. If the orgasmic dysfunction is judged to be due exclusively to the physiological effects of both a general medical condition and substance use, both Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction are diagnosed. Other mental disorders Male Orgasmic Disorder may also occur in association with other Sexual Dysfunctions (e.g., Male Erectile Disorder). If so, both should be noted. An additional diagnosis of Male Orgasmic Disorder is usually not made if the orgasmic difficulty is better accounted for by another mental disorder (e.g., Major Depressive Disorder). An additional diagnosis may be made when the orgasmic difficulty predates the mental disorder or is a focus of independent clinical attention. Sexual Dysfunction Not Otherwise Specified Several types of Sexual Dysfunction (e.g., ejaculation but without pleasurable orgasm, orgasm that occurs without ejaculation of semen or with seepage of semen rather the propulsive ejaculation) would be diagnosed as Sexual Dysfunction Not Otherwise Specified rather than as Male Orgasmic Disorder. Occasional orgasmic problems Occasional orgasmic problems that are note persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty are not considered to be Male Orgasmic Disorder. As males age, they may require a longer period of stimulation to achieve orgasms. The clinician must also ascertain that there has been sufficient stimulation to attain orgasm. DSM-5 Diagnostic Criteria A'''. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay: # Marked delay in ejaculation. # Marked infrequency or absence of ejaculation. '''B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C'''. The symptoms in Criterion A cause clinically significant distress in the individual. '''D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. Specify whether: * Lifelong: The disturbance has been present since the individual became sexually active. * Acquired: The disturbance began after a period of relatively normal sexual function. Specify whether: * Generalized: Not limited to certain types of stimulation, situations, or partners. * Situational: Only occurs with certain types of stimulation, situations, or partners. Specify current severity: * Mild: Evidence of mild distress over the symptoms in Criterion A. * Moderate: Evidence of moderate distress over the symptoms in Criterion A. * Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. Differential Diagnosis Another medical condition The major differential diagnosis is between delayed ejaculation fully explained by another medical illness or injury and and delayed ejaculation with a psychogenic, idiopathic, or comorbid psychological and medical etiology. A situational aspect to the complaint is suggestive of a psychological basis for the problem (e.g., men who can ejaculate during sexual activity with one sex but not to the other; men who can ejaculate with one partner but not another of the same sex; men with paraphilic arousal patterns; men who require highly ritualized activity to ejaculate during partnered sexual activity). Another medical illness or injury may produce delays in ejaculation independent of psychological issues. For example, inability to ejaculate can be caused by interruption of the nerve supply to the genitals, such as can occur after traumatic surgical injury to the lumbar sympathetic ganglia, abdominoperitoneal surgery, or lumbar sympathectomy. Ejaculation is thought to be under autonomic nervous system control involving the hypogastric (sympathetic) and pudendal (parasympathetic) nerves. A number of neurodegenerative diseases, such as multiple sclerosis and diabetic and alcoholic neuropahty, can cause inability to ejaculate. Delayed ejaculation should also be differentiated from retrograde ejaculation (i.e., ejaculation into the bladder), which may follow trans urethral prostatic resection. Substance/medication use A number of pharmacological agents, such as antidepressants, antipsychotics, alpha sympathetic drugs, and opioid drugs, can cause ejaculatory problems. Dysfunction with orgasm It is important in the history to ascertain whether the complaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs in the genitals, whereas the experience of orgasm is believed to be primarily subjective. Ejaculation and orgasm usually occur together but not always. For example, a man with a normal ejaculatory pattern may complain of decreased pleasure (i.e., anhedonic ejaculation). Such a complaint would not be coded as delayed ejaculation but could be coded as other specified sexual dysfunction or unspecified sexual dysfunction.